11. KEGAWATDARURATAN OBSTETRI.pptx

GYNECOLOGY AND OBSTETRIC EMERGENCIES

ABARHAM MARTADIANSYAH, MD.OG

GYNECOLOGIC EMERGENCIES• Vaginal bleeding• Lower abdominal or pelvic pain

OBSTETRIC EMERGENCIES• Maternal• Fetal• Both mother and fetus at risk

Gynecologic Emergencies

GYN Patient History

Vaginal Bleeding Considerations:Amount?

When and for how long?Likelihood of pregnancy?

LMP?Associated with pain, other functions?

Other medical problems?Obstetric history? (Gravida/Para)

Vaginal Bleeding DD:

• Polyp• Adenomyosis• Leiomyoma• Malignantcy – endometrial hyperplasia)• Coagulopathy• Ovulatory dysfunction• Endometrial• Iatrogenic• Not specified

GYN Patient History

Abdominal/Pelvic Pain Considerations:Onset? When did this start?

Provocation? Anything make it worse or better?Quality? Dull ache or sharp pain?

Radiation? Does the pain go anywhere?Severity? 1-10 Scale (onset & now)

Time? How long has it been going on?

Abdominal/Pelvic Pain DD:

• Endometriosis • Cyst torsion• Infected cyst• Tuboovarial abcess• Pelvic infalmmatory disease

Obstetric Emergencies

• Maternal – Hemorrhage (Prepartum, Intrapartum, Postpartum)– Gestational hypertension– Infection

• Fetal distress• Both maternal - fetal

MATERNAL DISTRESS : HEMORRHAGEPREPARTUM/INTRAPARTUM:

1st TM : miscarriage, ectopic pregnancy, H. molePlacenta previaPlacenta accreta/increta/percretaPlacental abruptionUterine rupture

POSTPARTUM:Retained placentaUterine atonyUterine inversionBirth trauma/laceration

MATERNAL DISTRESS : GESTATIONAL HYPERTENSION

• Gestational hypertension• Chronic hypertension• Chronic hypertension on superimposed

preeclampsia• Preeclampsia (mild-severe)• Ecklampsia

MATERNAL DISTRESS : INFECTION

• PROM• PPROM• OBSTRUCTED NEGLECTED LABOR

FETAL DISTRESS

• ANTEPARTUM:– Umbilical cord prolapse– Umbilical cord compression

• AT DELIVERY:– Shoulder dystocia– Vaginal breech delivery (head entrapment)

PLACENTA PREVIA • 1 in 200-250 deliveries• Complete, partial or marginal• Most diagnosed early resolve by third trimester

• ETIOLOGY:• Unknown• Previous uterine scar• Previous placenta previa• Advanced maternal age• Multiparity

PLACENTA PREVIA

Painless vaginal bleeding-third trimesterVaginal bleeding in 3rd trimester should be considered previa

until proven otherwiseUltrasound has eliminated the need of double set up to

diagnose previa as in the pastExpectant management if fetus immature and no active

bleedingCesarean deliveryUrgent/emergent cesarean delivery for active or persistent

bleeding or fetal distressRegional/GETA

Placentation

PLACENTA ACCRETA/ INCRETA/PERCRETA

• Linearly related to number of previous scars in presence of placenta previa

• PP+unscarred uterus-5 % risk of accreta• PP+one previous C/D-24% risk of accreta• PP+two previous C/D-47% risk of accreta• PP+three previous C/D-40% risk of accreta• PP+four previous C/D-67% risk of accreta• Combination of placenta previa and previous C/D-

Dangerous

PLACENTA ACCRETA/ INCRETA/PERCRETA

Placenta accreta, increta and percreta difficult to diagnose antepartum

Usually diagnosed when placenta doesn’t separate after cesarean or vaginal delivery

Color Doppler imaging or magnetic resonance imaging may diagnose the condition antepartum

Preoperative balloon catheters in internal iliac can be considered in cases diagnosed antepartum.

Prompt decision for hysterectomyPercreta may require surgeons skilled in pelvic dissection

PLCANTA ACCRETA/INCRETA/PERCRETA

GETA/Regional (CSE)Good IV access/ A line Level 1 or equivalent warmerCross matched bloodFFP/Cryo/Factor VII/Platelets Emergency hysterectomy more blood loss than elective

hysterectomyHemodilution/red cell salvage can be considered in

Jehovah’s witnessRegional may be associated with reduced blood loss but

may complicate treatment of hypotension in a bleeding patient.

PLACENTAL ABRUPTION• I in 77 to 1 in 86 deliveries• ETIOLOGY:• Cocaine• Hypertension: Chronic or pregnancy induced• Trauma• Heavy maternal alcohol use• Smoking• Advanced age and parity• Premature rupture of membranes• History of previous abruption

PLACENTAL ABRUPTION• Vaginal bleeding-Classical presentation• May not always be obvious • 3000 ml or more blood can be sequestered behind placenta

in concealed bleeding • Uterus can’t selectively constrict abrupted area• Decreased placental area-fetal asphyxia• 1 in 750 deliveries-fetal death• Severe neurological damage in some surviving infants• Upto 90% abruptions-mild to moderate

Placental Abruption

PLACENTAL ABRUPTION • Problems: Hemorrhage, Consumptive coagulopathy, Fetal

hypoxia, Prematurity• Low fibrinogen/ Factor V, Factor VII and platelets and

increased fibrin split products• Management depends on severity of situation• Vaginal delivery-Fetus and mother stable• Urgent/Emergent C/D- Fetal distress or severe

hemorrhage• Be prepared for massive blood loss with C/D• Couvelaire uterus may not contract after delivery• On rare occasions, internal iliac ligation/hysterectomy may

be necessary

UTERINE RUPTURE• Prepartum, intrapartum or postpartum• ETIOLOGY:• Prior cesarean delivery especially classical cesarean scar• Rupture of myomectomy scar• Precipitous labor• Prolonged labor with cephalopelvic disproportion• Excessive oxytocin stimulation• Abdominal trauma• Grand multiparity • Iatrogenic• Direct uterine trauma-forceps or curettage

UTERINE RUPTURESevere uterine or abdominal pain or shoulder painDisappearance of fetal heart tonesVaginal or intraabdominal bleedingHypotensionVBAC: Change in uterine tone or contraction pattern and

FHR changes and not pain during uterine ruptureEmergent C/D may be necessaryUterine repair/Hysterectomy depending on situation

RETAINED PLACENTA• 1% of deliveries• Ongoing blood loss• Manual exploration for removal• You need uterine relaxation and analgesia• Anaesthesia depending on clinical situation• Oxytocics after removal of placenta

UTERINE ATONYMost common cause of postpartum hemorrhageFollows 2-5% deliveriesETIOLOGY:MultiparityPolyhydramniosMacrosomiaChorioamnionitisPrecipitous labor or excessive oxytocin use during laborProlonged laborRetained placentaTocolytic agents Halogenated agents >0.5 MAC

UTERINE ATONYManagement (Important Points)• Vaginal bleeding > 500 ml• Manual examination of uterus• Volume resuscitation• Infusion of oxytocics + bimanual compression of uterus• Evaluation for retained placenta

OXYTOCIC DRUGSOxytocin:20-40U/L-Vasodilation, hypotension,

hyponatremia, no benefit after 40 UMethylergonovine:0.2 mg IM, Max. 0.4 mg-

Vasoconstriction, ↑PA pressures, coronary artery vasospasm, hypertension, CVA, nausea and vomiting

Carboprost or hemabate (prostaglandin F2α analog): 0.25 mg IM or IU, Max 1.0 mg –Vasoconstriction, systemic and pulmonary hypertension, bronchospasm, V/Q mismatch, nausea, diarrhea

Misoprostol 800 mg PR. Minimal side effects

UTERINE INVERSION Uncommon problem • Results from inappropriate fundal pressure or• Excessive traction on umbilical cord especially if placenta

accreta is present• Mass in the vagina• Uterine atony• Maternal shock and hemorrhage• Volume replacement• Analgesia for the procedure• Uterine relaxation for replacement• Oxytocics following replacement

BIRTH TRAUMA/LACERATIONS

Lesions range from laceration to retroperitoneal hematoma requiring laparotomy

Can result from difficult forceps delivery/Precipitous vaginal delivery/Malpresentation of fetal head (OP)/Laceration of pudendal vessels/Clinical presentation of postpartum bleeding with

contracted uterusEpidural/MAC/GETA depending on the clinical scenario

Pre-eclampsia

• A pregnancy-induced hypertension• ≥ 20 weeks gestation• Previously normotensive• ≥140/90 mmHg on at least two occasions• + proteinuria ≥ 0.3g in 24h• ± oedema• Multisystem disease

Severe pre-eclampsia

• Diastolic blood pressure ≥ 110 mmHg on two occasions

• Or systolic blood pressure ≥ 170mmHg on two occasions

• Significant proteinuria (at least 1g/litre)

Risk factors

• First pregnancy (primigravida)• Age <20 or >35 yrs• Previous Hx or FHx• Multiple pregnancy• Certain underlying medical conditions

– Pre-existing hypertension (superimposed pre-eclampsia)

– Pre-existing renal disease– Pre-existing diabetes– Antiphospholipid antibodies

Clinical features

• History– Usu. asymptomatic – Headache– Drowsiness– Visual disturbance– Nausea/vomiting– Epigastric pain

• Examination– Oedema (hands and face)– Proteinuria on dipstick– Epigastric tenderness (liver involvement)

Complications (multisystem)• Head/brain

– Eclampsia, Stroke/ cerebrovascular haemorrhage• Heart

– Heart failure• Lung

– Pulmonary oedema, Bronchial aspiration, ARDS• Liver

– Hepatocellular injury, liver failure, liver rupture• Kidneys

– Renal failure, oliguria• Vascular

– Uncontrolled hypertension, DIC, HELLP

Complications (fetal)

• IUGR• Oligohydramnios• Placental infarcts• Placental abruption• Uteroplacental insufficiency• Prematurity• PPH

Investigations• Maternal

– FBC – platelets (HELLP)– Coag screen if platelets abnormal– U&Es (urate, renal failure)– LFTs (liver involvement)

• Fetal– USS

• Fetal size/growth, amniotic fluid volume, umbilical cord blood flow

– CTG

Management• No cure except delivery; Aim to minimise risk to

mother in order to permit continued fetal growth• Antihypertensives

– Methyldopa– Labetalol– Nifedipine

• Eclampsia– Magnesium sulphate

• Induction of labour– Antenatal steroids

FETAL HEART RATEBaseline fetal heart rate, variability, decelerations or

accelerationsNormal FHR: 110-160 bpmTachycardia: Maternal fever, infection, terbutaline, atropine,

hyperthyroidism, tachyarrythmia, hypoxemiaBradycardia: Fetal autonomic response to baroreceptor or

chemoreceptor stimulationVariability: Most reliable index of fetal well being; variability is

baseline fluctuations in FHR over 2 cycles/minCan be absent, minimal (<5 bpm), moderate (6-25 bpm) or

marked (>25 bpm)

Early decelerations

Variable decelerations

Variable decelerations - severe

Late Decelerations

Variable deceleration with late component

Fetal Tachycardia

Sinusoidal Pattern

UMBILICAL CORD PROLAPSE:Definition

• Umbilical cord prolapse exists when a loop of cord is present below the presenting part and the membranes are ruptured.

• Incidence is approximately 0.2% of births

• Risk of perinatal morbidity/mortality from asphyxia secondary to mechanical compression of the cord between the presenting part and the pelvis, or spasm of cord vessels secondary to cold or manipulation.

Cord Prolapse Occult Cord

Cord ProlapseTrue Prolapsed Cord

Risk Factors

Fetal Malpresentation Prematurity Polyhydramnios Multiple pregnancy Anencephaly Maternal Contracted pelvis Pelvic tumour Other Long cord Sudden rupture of membranes, esp. if polyhydramnios

Management

• Obstetric Intervention • amniotomy, FSE application • expectant management of PPROM• Recommendations • Diagnosis • Vaginal examination to confirm diagnosis of prolapsed

cord and to ascertain cervical dilatation.• Call for help – senior midwife, obstetric registrar,

anaesthetist • Determine that fetal heart present and monitor by CTG.

If fetus is viable -

• Discontinue Syntocinon, administer oxygen by face mask • Make preparations for emergency Caesarean section - IV

access, group and save • Elevation of the presenting part of the fetus above the pelvic

inlet will relieve cord compression. This can be achieved manually, in which case the hand should remain in the vagina until delivery. Alternatively the patient may be placed in the knee chest position, or the bladder may be filled with 500mls saline through a Foley catheter. The catheter should be clamped, then unclamped to allow bladder emptying when the skin incision is made at Caesarean section.

• Anaesthesia • Delivery will usually be by Caesarean

section under GA. However, where the bladder filling has been employed and there is no evidence of fetal distress, regional anaesthesia may be considered.

Vaginal delivery If the cervix is fully dilated then instrumental

delivery may be appropriate but should only be undertaken by experienced obstetric staff, i.e. Consultant or experienced SpR.

If no FH auscultated – confirm intrauterine death using ultrasound and aim for vaginal delivery.

If fetus of a non-viable gestation – discuss with senior obstetric staff and aim for vaginal delivery

Shoulder Dystocia

• Bony prominence disorder where the anterior fetal shoulder becomes impacted behind the suprapubic arch of the maternal pelvis following the birth of the fetal head.

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Occurrence

• 0.3 – 1% birth weight 2500 – 4000gms• 5-7% birth weight 4000 – 4500gms

• 50% occur in babies of normal birth weight

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Risk factors• Antenatal

– Gestational Diabetes– Short Stature– Previous shoulder

dystocia– maternal wgt gain > 20

kgs– Pelvic anomalies– Fetal macrosomia– Postdates

• Intrapartum– Prolonged second stage– precipitate labour– Instrumental birth– Head bobbing in second

stage

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Identification of Shoulder Dystocia

• Turtle sign following birth of the baby’s head. The baby’s head will retract right back against the perineum.

• Baby does not birth using normal traction

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Risk Reduction

• Good diabetes control• Birthing women on all fours or in

McRoberts or upright position where risk is identified / suspected

• Elective C/S – need to increase the rate 5 to 6 fold to avoid 1 case of shoulder dystocia

• IOL at term has not shown to reduce the rate

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Mortality/Morbidity• Maternal

– 3rd – 4th degree tears– Genital tract trauma– Uterine atony – PPH

• Fetal– # clavical– Erb’s palsy– Brachial nerve palsy– Hypoxia – Fetal

blood pH will fall by 0.04/min, so a pH of 7.25 over 7 min will fall to 6.97

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Interventions

• Reduction Manoeuvres aim to– Increase the functional size of the pelvis

(McRoberts)– Decrease the bisacromial diameter (Suprapubic

Pressure and Rubins)– Change the relationship of the bisacromial

diameter with the bony pelvis (Woodscrew)

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HELPERR ©

• Pressure – suprapubic– CPR style pressure as a constant downward and

lateral force over the anterior shoulder to facilitate adduction of the fetal shoulders and reduce the bisacromial diameter. Pressure is applied over the fetal back.

– After 30 seconds a rocking motion of the hands can be tried to achieve the same outcome.

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HELPERR ©

• Enter manoeuvers– Rubins’ 2– 30 secs

Remove the bottom of the bed or turn the woman sideways to improve access to the perineum

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Woods screw

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Reverse Woods screw

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Other interventions

The following manoeuvres are in the scope of practice for medical officers:

• Fracture the clavical• Zavanelli Manoeuvre• Symphysiotomy

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Practice Points

• Drop the head of the bed – lie the woman flat

• Improve access for enter manoeuvres by removing the bottom of the bed or lying the woman sideways on the bed

• Encourage NO pushing during enter manoeuvres

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Documentation

• Timing• Interventions• Assistants• Manoeuvres• Outcomes:

– maternal– neonatal (incl cord gases)

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Post Birth Considerations

• Debrief with parents and support people• staff debrief• case review

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BREECH (HEAD ENTRAPMENT

True obstetric emergencySmaller body pushed through partially dilated cervix

trapping aftercoming headVaginal breech delivery-Discouraged by ACOG5% vs.1.6% deaths-Vaginal vs. C/D (Study in 2000 women)Incisions in cervix to enlarge opening or skeletal muscle

and cervical relaxation or CDEpidural-prevents early pushing before cervix is fully

dilated and relaxes the perineumGETA may be necessary for uterine and perineal relaxation

Thank you

11. KEGAWATDARURATAN OBSTETRI.pptx

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